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1 DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH Phone: Fax: Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain Medicine Hulda B. Magnadottir, M.D. NAME ADDRESS CITY, STATE, ZIP Kristin J. Jamieson, PA-C Alyssa M. Pearl, PA-C Please complete all pages of this medical history form before reporting for your examination. DOB: Age: Sex: M F Phone: ( ) - Married/ Single (circle) Handedness: L R (circle) Height: Normal Weight: Family Dr. Doctor who referred you to this office: For what problem are you being referred to this office: When did this problem first begin: Do you believe that this problem is work related: Yes, No, If yes, explain: Did this problem begin after an injury: Yes, No, If yes what kind of injury: What were you doing when the problem first started: What makes the problem better: What makes the problem worse:

2 The problem is (circle) : constant comes and goes (leave blank) Allergies: Please list medications that you are allergic to: Please list seasonal or environmental allergies: Current medications: Please list all your current medications with dosages: 1) 5) 2) 6) 3) 7) 4) 8) Past medical history: Do you have any of the following medical conditions: High blood pressure: Yes No Year diagnosed: High cholesterol: Yes No Year diagnosed: Heart Disease: Yes No Cardiologist: What type: When was last Cardiology Appt: Diabetes: Yes No Year diagnosed: Asthma: Yes No Year diagnosed: Ulcers: Yes No Year diagnosed: Irregular heart rate: Yes No Year diagnosed: Migraine headaches: Yes No Year diagnosed: Seizures/Epilepsy: Yes No Year diagnosed: Arthritis: Yes No Year diagnosed: Lung disease: Yes No Year diagnosed: What type: Kidney disease: Yes No Year diagnosed: What type: Thyroid disease: Yes No Year diagnosed: What type: Skin disease: Yes No Year diagnosed: What type: Liver/Intestinal disease: Yes No Year diagnosed: What type: Cancer: Yes No Year diagnosed: What type: Other: Have you ever had any of the following: Heart Attack: Yes No Date: Heart Bypass Surgery: Yes No Date: Neck Injury: Yes No Date: Back Injury: Yes No Date: Stroke: Yes No Date:

3 Head injury: Yes No Year it occurred: Did you black out? Yes No Car accident: Yes No Year it occurred: Did you black out? Yes No Please list all previous hospitalizations and surgeries that you have had. 1) When? Where? 2) When? Where? 3) When? Where? 4) When? Where? 5) When? Where? 6) When? Where? Social history: Occupation: (if retired, list previous job) Tobacco use: ( ) Never smoked ( ) Used to smoke packs per day but quit in (year) ( ) Currently smoke packs per day, started smoking at age Alcohol use: ( ) Have never used alcohol ( ) Drink occasionally ( ) Drink daily ( ) Quit drinking in: ( ) I usually drink (circle) beer wine mixed drinks And I usually have drinks in one day. Family history: Mother: ( ) Alive ( ) Deceased Age Cause of death if deceased: Father: ( ) Alive ( ) Deceased Age Cause of death if deceased: Age of brothers: If deceased, indicate age at time: Age of sisters: If deceased, indicate age at time: Age of children: Do/did any of these family members have any of the following medical conditions: High blood pressure: Migraine headaches: Alzheimer s disease: Multiple sclerosis: Heart attack: Diabetes: Seizures: Tremors: Stroke: Carpal tunnel syndrome Y / N Who: Other: :

6 GUARANTOR INFORMATION Who carries the insurance? DOB: SSN#: Their relationship to you: Employer and address which insurance is through *PLEASE HAVE RECEPTIONIST TAKE A COPY OF YOUR INSURANCE CARD.* **DOES YOUR INSURANCE REQUIRE A REFERRAL?** If so, did you get one? Please let the receptionist know. I authorize payment of medical benefits to Upper Valley Neurology Neurosurgery, PC for all services rendered. I understand I am financially responsible for any balances not fully paid by my insurance company. I hereby authorize the release of my medical information related to these claims to my insurance company. Signature Date ***************************************************************************** ***************************************************************************** If you are being seen due to an accident at work please complete the following: ACCIDENT/WORKERS COMPENSATION INFORMATION Date of accident: Claim #: Is this a workers compensation injury? (If yes, please indicate place of employment in which the accident occurred, their address, and phone number.) Workers compensation/liability insurance name, address and phone number:

Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have

Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child

GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:

Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last

Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer

NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)

Welcome to Avenstar Pain Specialists! Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best

Name: Address: Home Phone: Cell Phone: Email Address: Date of Birth: Primary Care Physician: Why have you been referred for a Cardiovascular Genetics Appointment? Have you had a genetics evaluation? If

PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING

REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please

Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit

Welcome! Thank you for choosing our practice for your eye care needs! Please fill out our new patient registration paperwork. So we may eliminate any potential waiting time, please fax the completed forms

MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems

Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax

Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other

(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address

HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:

Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken

Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last

p In order for us to obtain a complete medical history, it is important for you to fill out this form in its entirety. Every item needs to be filled out. This information will be entered into our Electronic

PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)

Welcome to Capital Endocrinology! We are happy to have you as a patient in our practice. Please take note of the following policies. Following these policies will help in making your visit as efficient

WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:

CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you